Enterovirus D68 (EV-D68) Patient Summary Form

Enterovirus D68 (EV-D68) Patient Summary Form

To be completed for all patients for whom specimens are being submitted to CDC for EV-D68 typing. As soon as possible, please 1) notify and send completed form to your local/state health department, and 2) include a hard copy of the form along with the 50.34 form for specimen shipment.

Today’s Date:

Name of person filling in form:

Phone:

Email:

Hospital / Health Care Facility Name:

STATE:

COUNTY:

Hospital ID:

State ID:

Specimen ID (as submitted on 50.34 form for specimen shipment):

If multiple specimens are submitted per patient, please include additional specimen IDs in table below

Patient Sex: M F Age: Days Months Years Patient’s State of Residence

Race: Asian Black or African American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native

White (More than one box can be checked) Ethnicity: Hispanic Non-Hispanic

Date of symptom onset:

Symptoms (mark all that apply): Fever / Highest recorded temperature (°F / °C ) Chills Cough Wheezing Sore throat

Runny nose Shortness of breath / difficulty breathing Tachypnea Retractions Cyanosis Vomiting Diarrhea Rash

Lethargy Seizure Other (describe):

Does the patient have any comorbid conditions? (mark all that apply): None Unknown Asthma Reactive airway disease

Bronchopulmonary dysplasia Cardiac disease Immunocompromised Prematurity, if yes gestational age

Other (describe):

Abnormal Chest radiograph Yes No Unknown Abnormal Chest CT Yes No Unknown

Yes / No / Unknown
Is/Was the patient: Hypoxic (sat <93%) on room air?
Treated with supplemental oxygen?
Treated with bronchodilators?
Treated with antibiotics?
Hospitalized? If Yes, admission date:
If Yes, was the patient admitted to the Intensive Care Unit (ICU)?
If Yes was the patient placed on non-invasive ventilation (BiPAP/CPAP)
If Yes, was the patient intubated?
If Yes, was the patient placed on ECMO?
Did the patient die? If Yes, date of death:
General Pathogen Laboratory Testing (mark all that apply)
Pathogen / Pos / Neg / Pending / Not Done / Pathogen / Pos / Neg / Pending / Not Done
Influenza A PCR / Rhinovirus and/or Enterovirus
Influenza B PCR / Coronavirus (not MERS-CoV)
Influenza Rapid Test / Chlamydophila pneumoniae
RSV / Mycoplasma pneumoniae
Human metapneumovirus / Legionella pneumophila
Parainfluenzavirus / Streptococcus pneumoniae
Adenovirus / Blood culture Yes No If positive, which bacteria:
Other: / CSF culture Yes No If positive, which bacteria:
Other: / Sputum culture Yes No If positive, which bacteria:
Enterovirus Typing - Specimen Type / Date Collected / Specimen ID / Enterovirus Typing - Specimen Type / Date Collected / Specimen ID
NP OP NP/OP (check one) / Bronchoalvelolar lavage (BAL)
Nasal wash / aspirate / Tracheal Aspirate
Sputum / Stool/Rectal swab
Other: / Other:

To be completed by CDC: Patient ID:

CSID:

CSID:

CSID:

CSID:

CSID:

Version 1.0 (fillable), September 12, 2014